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Per Hlmich, Pernille Uhrskou, Lisbeth Ulnits, Inge-Lis Kanstrup, Michael Bachmann Nielsen, Anders Munch Bjerg,
Kim Krogsgaard
Summary Introduction
Groin pain is a problem for athletes in several sports.
Background Groin pain is common among athletes. A major
Among male soccer players the incidence of groin pain is
cause of long-standing problems is adductor-related groin
1018% per year.13 Groin pain can be ascribed to various
pain. The purpose of this randomised clinical trial was to
disorders, few of which are well defined. There is no
compare an active training programme (AT) with a
consensus on definitions or diagnostic criteria. However,
physiotherapy treatment without active training (PT) in the
adductor-muscle pain is a frequent cause of groin pain4,5
treatment of adductor-related groin pain in athletes. and is known to cause long-standing problems.4
Methods 68 athletes with long-standing (median 40 The non-operative treatments of groin pain in athletes
weeks) adductor-related groin painafter examination are not based on randomised clinical trials.611 Most of the
according to a standardised protocolwere randomly studies on operative treatment of groin injuries were
assigned to AT or PT. The treatment period was 812 retrospective,1217 and the few prospective studies were not
weeks. 4 months after the end of treatment a standardised randomised.18
examination was done. The examining physician was In sports medicine various training programmes to
unaware of the treatment allocation. The ultimate outcome treat overuse injuries in particular have been designed
primarily on an empirical basis. However, the efficacy of
measure was full return to sports at the same level without
training programmes for a few diagnostic entities such as
groin pain. Analyses were by intention to treat.
functional instability of the ankle19 and low-back pain,20
Findings 23 patients in the AT group and four in the PT has been documented in randomised clinical trials.
group returned to sports without groin pain (odds ratio, Muscular imbalance of the combined action of the
multiple-logistic-regression analysis, 127 [95% CI muscles stabilising the hip joint could, from an
34472]). The subjective global assessments of the anatomical point of view, be a causative factor of
effect of the treatments showed a significant (p=0006) adductor-related groin pain.21 Muscular fatigue and
linear trend towards a better effect in the AT group. A per- overload might lead to impaired function of the muscle
protocol analysis did not show appreciably different and increase the risk of injury. The adductor muscles act
results. as important stabilisers of the hip joint.22 They are,
therefore, exposed to overloading and risk of injury if the
Interpretation AT with a programme aimed at improving stabilisation of the hip joints is disturbed. Laboratory
strength and coordination of the muscles acting on the studies have shown that strengthening exercises could
pelvis, in particular the adductor muscles, is very effective protect muscles from injury.23
in the treatment of athletes with long-standing adductor- The purpose of this randomised clinical trial was to
related groin pain. The potential preventive value of a short compare an active training programme with a
programme based upon the principles of AT should be conventional physiotherapy programme in the treatment
assessed in future, randomised, clinical trials. of severe and incapacitating adductor-related groin pain
in athletes.
Lancet 1999; 353: 43943
The treatment moralities were: a physiotherapy
treatment without active training (PT) with elements of
both passive and active therapy put together according to
the contemporary practice among physicians and
physiotherapists working in the field of sports injuries,
and an active training programme (AT) aimed at
improving the coordination and strength of the muscles
stabilising the pelvis and hip joints, in particular the
adductor muscles.
Odds ratio (95% CI) residual groin pain at clinical examination and had
Univariate analysis Multiple logistic-regression returned to sport at the same level or an even higher level
analysis of activity without groin pain, compared with only 14% in
Treatment the PT group. The patients subjective assessments of the
AT 157 (44557) 127 (34472) treatments accorded with the objective outcome
PT* 1 1 measures. AT resulted in significantly better subjective
Groin pain assessment than PT.
Unilateral 98 (20469) 66 (12372)
Bilateral* 1 1
AT was a group treatment, and PT was an individual
treatment. This difference was taken into account when
Level of pain at entry
Moderate 33 (1197) the amount of physiotherapy attendance given to each
Severe* 1 patients was planned. The number of treatments with
*Reference category. regard to physiotherapy attendance received in the AT
Table 3: Univariate and multiple logistic-regression analysis of group was a median of 15 treatments and in the PT
the three significant variables influencing outcome measures group 14 treatments.
The patients included in our study were very active
univariate and the multiple-logistic-regression analysis.
before the injury; most trained three to four times a week
Treatment, unilateral or bilateral, and severity of pain
(table 1) but at study entry they were athletically
were predictors of outcome in the univariate analysis. In
disabled. They had been injured for 9 months (median),
the multiple-logistic-regression analysis, only treatment or
and 75% had ceased to participate in sports because of
bilateral symptoms were independent predictors. After
groin pain. Because most of the patients had abstained
adjustment for unilateral groin pain, the odds ratio for the
from sport for 4 months without improvement of
AT treatment was 127 (95% CI 34472). There were
symptoms and were judged to need therapy, a control
no significant interactions between the explanatory group consisting of those who received no therapy, and
variables. A per-protocol analysis including the 59 who did not participate in any sport, would have been
patients who completed the study did not show unethical.
appreciably different results. The PT group used methods derived from physiotherapy:
The subjective global assessment of the effect of manual techniques (transverse friction massage),
treatment in the two groups based solely on results from electrotherapy (laser and transcutaneous electrical nerve
patients completing the study (per-protocol analysis) are stimulation), and exercise therapy (stretching). The PT
shown in table 4. No patient assessed his result as worse programme was constructed from a range of techniques
or much worse. There was a significant (p=0006) linear including, for example, ultrasonography, muscle massage,
trend towards better effect of the AT treatment. The and heat or cold application.
relation between the subjective global assessment and the The AT group used exercises aimed at muscular
outcome measures is shown in table 4. Almost all patients strengthening with special emphasis on the adductor
(26 of 27) rates as excellent assessed their condition to be muscles, as well as training muscular coordination to
much better. The linear trend was significant (p=0001). improve the postural stability of the pelvis.
In the AT treatment group, 23 (79%) of the athletes Passive treatments such as ultrasonography (59%), soft
completing the study returned to sports activity at their laser (48%) and massage (47%) had been used by
previous level without any symptoms of groin pain. The patients frequently in the past, but active treatment such
median time from entering the study until complete as stretching (56%) was also common. None of the
symptom-free return to sport was 185 weeks (range participants had had a systematic intensive course of
1326). The range of motion of the hip-joint abduction physiotherapy before. Active training exercise similar to
increased significantly in both treatment groups those used in the AT group had been tried by about 20%
(p=00004), but no difference was found between the of patients.
groups. The adduction strength improved significantly in Stretching is known to increase range of joint motion in
the AT group compared with the PT group (p=0001) the leg.2628 The patients in the PT group used stretching
but the VO2-max values (table 1) of the two treatment exercises for the adductor muscle both during treatment
groups did not change during the treatment period. with the physiotherapist and as home exercise on the days
between treatment days. The patients in the AT group
Discussion were not allowed to do stretching exercises for the
We found that treatment of long-standing adductor- adductor muscle at all; nonetheless they had the same
related groin pain with an active programme of specific increase of hip-joint range of motion as the PT group. In
the AT group, pain was initially a limiting factor to the
exercises aimed at improving strength and coordination
range of motion in some of the exercises, but, as the
of the muscles acting on the pelvis was significantly better
muscle coordination and strength increased and the groin
than a conventional physiotherapy programme.
pain decreased, the load and the range of motion
Moreover, 79% of the patients in the AT group had no
increased. Tolerance towards an increased range of
Subjective global Treatment Treatment outcome motion might thereby be achieved. Two examples of this
assessment
AT* PT* Not-excellent Excellent
type of exercise are the one-leg exercise on the sliding
board (module I, exercise 6) and the weight-pulling
Much better 22 13 9 26
Better 7 14 20 1
exercise (module II, exercise 4). Ekstrand has suggested
Not better 0 3 3 0 that decreased range of motion in the abduction of the
p=0006. p=0001. hip joint could predispose to adductor-related injuries.29
Table 4: Subjective global assessment of AT and PT and the Stretching exercises are therefore commonly
relationship between subjective global assessment and recommended in the treatment of long-standing
outcome measures of the treatments adductor-related groin pain. The results of our study do
not support this recommendation. Another possibility is 8 Balduini FC. Abdominal and groin injuries in tennis. Clin Sports Med
1988; 7: 34957.
that stretching of the adductor muscle and thereby
9 Swain R, Snodgrass S. Managing groin pain. Psysician Sportsmed 1995;
pulling on the insertions at the pubic bone might worsen 23: 5566.
the injury. But this possibility and an effect of stretching 10 Hasselman CT, Best TM, Garrett WE. When groin pain signals an
and strengthening training of the adductors in the adductor strain. Physician Sportsmed 1995; 23: 5360.
prevention of groin injuries, are merely theoretical. 11 Holt MA, Keene JS, Graf BK, Helwig DC. Treatment of osteitis pubis
in athletes, results of corticosteroid injections. Am J Sports Med 1995;
Randomised clinical trials are needed to assess such 23: 60106.
ideas. 12 Taylor DC, Meyers WC, Moylan JA, Bassett FH, Garrett WE.
The exercises in the AT group involved limited muscle Abdominal musculature abnormalities as a cause of groin pain in
groups and were not aimed at improving endurance. The athletes. Am J Sports Med 1991; 19: 23942.
13 Hackney RG. The sports hernia: a cause of chronic groin pain. Br J
AT programme as such was insufficient to affect the Sports Med 1993; 27: 5862.
maximum oxygen uptake. The main elements of the AT 14 Martens MA, Hansen L, Mulier JC. Adductor tendinitis and muscular
programme are restoration of muscle strength in rectus abdominis tendopathy. Am J Sports Med 1987; 15: 35356.
combination with balance and coordination training. The 15 kermark C, Johansson C, Tenotomy of the adductor longus tendon
hypothesis that similar treatment principles would be in the treatment of chronic groin pain in athletes. Am J Sports Med
1992; 20: 64043.
effective in the case of other injuries related to tendons 16 Klebo P, Karlsson J, Swrd L, Peterson L. Ultrasonography of
and tendon insertions should be investigated in chronic tendon injuries in the groin. Am J Sports Med 1992; 20:
randomised clinical trials, as should the potential benefit 63438.
of a shorter programme of AT. 17 Bradshaw C, McCrory P, Bell S, Brukner P. Obturator nerve
entrapment, a cause of groin pain in athletes. Am J Sports Med 1997;
25: 40208.
Contributors 18 Malycha P, Lovell G. Inguinal surgery in athletes with chronic groin
Per Hlmich was responsible for the study design, running of the study, pain: the sportsmans hernia. Aust N Z J Surg 1992; 62: 12325.
analysis, and writing. Pernille Uhrskov and Lisbeth Ulnits ran the 19 Tropp H. Functional instability of the ankle joint (thesis) University of
physiotherapy programme. Michael Bachmann Nielsen did the Sweden: Linkping, 1985.
radiological investigations. Inge-Lis Kanstrup did the clinical physiological 20 Manniche C, Hesselse G, Bentzen L, Christensen I, Lundberg E.
investigations. Anders Munch-Bjerg did the statistical analysis. Clinical trial of intensive muscle training for chronic low back pain.
Kim Krogsgaard did analysis and writing. All the authors read and Lancet 1988; 31: 147376.
revised the manuscript. 21 Hlmich P. Adductor related groin pain in athletes. Sports Med Arth
Acknowledgments Rev 1998; 5: 28591.
This study was supported by grants from the Danish Research Council of 22 Morrenhof JW. Stabilisation of the human hip-joint (thesis).
Sport, the Danish Sports Federation, and the Scientific Commission of Netherlends: Rijksuniversiteit to Leiden, 1989.
TEAM Denmark. 23 Garrett WE, Safran MR, Seaber AV, Glisson RR, Ribbeck BM.
Biomechanical comparison of stimulated and nonstimulated skeletal
muscle pulled to failure. Am J Sports Med 1987; 15: 44854.
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